NHS England
NHS / Health Body
Noted
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Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Josh Yemi Tarrant who died on 1 November 2023.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 9 February 2026 concerning the death of John Yemi Tarrant on 1 November 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Mr Tarrant’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Mr Tarrant’s care have been listened to and reflected upon.
I am grateful for the further time granted to respond to your Report, and I apologise for any anguish this delay may have caused to Mr Tarrant’s family and friends. I realise that responses to Coroners’ Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones, and I appreciate this will have been an incredibly difficult time for them.
Your report raised concerns around the lack of training provided to prison healthcare staff in relation to Acute Behavioural Disturbance (ABD) (despite the clear advice of Prison Service Order 1600 (2005)) and if prison nurses remain unaware of ABD and the need to treat it as a medical emergency, then further deaths are likely in future.
Background on Acute Behavioural Disturbance
The term ‘Acute Behavioural Disturbance' (ABD) is not a formal diagnosis within the International Classification of Diseases (ICD-11), which is the global diagnostic tool used in the NHS. ABD is generally used to describe behaviours linked with extreme agitation or distress, which may indicate a potentially life-threatening physical health emergency. NHS England recognises the importance of ensuring that individuals presenting in extreme distress receive timely, safe and effective care. ABD is not a specific condition with a set of defined symptoms. It is not common and it is very difficult to identify the difference between agitation, antisocial behaviour, deliberate violent behaviour and ABD. There is no reliable way to determine mild or severe ABD in the pre-hospital setting nor over the phone during a triage process. ABD is a Medical Director for Mental Health and Neurodiversity NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
20th April 2026
complex but known clinical presentation, and the Royal College of Psychiatrists has published guidelines on managing ABD.
We have considered your concerns to inform our learning and we have consulted with , Consultant Forensic Psychiatrist and member of NHS England Health and Justice Clinical Reference Group.
Given the rarity and complexity of ABD and the operational realities of prisons, it is not reasonable to expect prison healthcare staff to diagnose ABD reliably. The critical safety issue is recognition of severe agitation accompanied by physiological red flags and escalation as a medical emergency.
In 2025 NHS England developed a framework for healthcare roles and responsibilities for planned and unplanned use of force in adult prisons and immigration removal centres which was communicated to all healthcare providers in August 2025. This framework supports HMPPS and Home Office policy documents and makes clear healthcare requirement to attend all planned, and where possible, unplanned use of force incidents.
This framework strengthens the expectations of healthcare staff and provides explicit guidance around warning signs of ABD. This revised framework offers clearer boundaries and ensures that all staff involved in use of force events share a consistent approach to managing risk, including the risk of ABD. Use of force is the terminology used by HMPPS and Home Office and includes the use of physical, mechanical and chemical restraint.
We will be sharing the details of this report with all prison and Immigration Removal Centre healthcare providers with an action to ensure all establishments have a clear red flag criteria and emergency escalation pathway within existing healthcare training structures and operation briefings. This should include a focus on early recognition of deterioration, prompt ambulance activation where indicated, minimising restraint duration and maintaining continuous observation until handover, with routine governance review of such incidents.
In addition, the findings, information and any learning from this case will be tabled at a future NHS England Health and Justice Delivery Oversight Group (HJDOG). The HJDOG is the senior leadership forum, which holds responsibility for the oversight of delivery and continuous improvement in Health and Justice commissioned services, through both national and regional teams. All health and justice related Reports to Prevent Future Deaths are shared and discussed at the HJDOG, and assurance is sought from regions where learning and action is identified.
Regional Response
South East Regional Colleagues have shared reports around the Trust’s PSII and PPOs independent review. South East Regional Colleagues have advised that both sets of reports identify that clinical staff should receive training in managing violence, aggression and mental health crises, as well as the fact some actions taken by staff , particularly around restraint, were not with current guidance and policy. Neither report shared mentions ABD or ‘Excited Delirium’, suggesting that Mr Tarrant’s presentation
was directly related to cocaine use and exacerbated by a heart condition, which the prison staff had no knowledge of at the time, as it was only detected postmortem.
I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Mr Tarrant, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 9 February 2026 concerning the death of John Yemi Tarrant on 1 November 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Mr Tarrant’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Mr Tarrant’s care have been listened to and reflected upon.
I am grateful for the further time granted to respond to your Report, and I apologise for any anguish this delay may have caused to Mr Tarrant’s family and friends. I realise that responses to Coroners’ Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones, and I appreciate this will have been an incredibly difficult time for them.
Your report raised concerns around the lack of training provided to prison healthcare staff in relation to Acute Behavioural Disturbance (ABD) (despite the clear advice of Prison Service Order 1600 (2005)) and if prison nurses remain unaware of ABD and the need to treat it as a medical emergency, then further deaths are likely in future.
Background on Acute Behavioural Disturbance
The term ‘Acute Behavioural Disturbance' (ABD) is not a formal diagnosis within the International Classification of Diseases (ICD-11), which is the global diagnostic tool used in the NHS. ABD is generally used to describe behaviours linked with extreme agitation or distress, which may indicate a potentially life-threatening physical health emergency. NHS England recognises the importance of ensuring that individuals presenting in extreme distress receive timely, safe and effective care. ABD is not a specific condition with a set of defined symptoms. It is not common and it is very difficult to identify the difference between agitation, antisocial behaviour, deliberate violent behaviour and ABD. There is no reliable way to determine mild or severe ABD in the pre-hospital setting nor over the phone during a triage process. ABD is a Medical Director for Mental Health and Neurodiversity NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
20th April 2026
complex but known clinical presentation, and the Royal College of Psychiatrists has published guidelines on managing ABD.
We have considered your concerns to inform our learning and we have consulted with , Consultant Forensic Psychiatrist and member of NHS England Health and Justice Clinical Reference Group.
Given the rarity and complexity of ABD and the operational realities of prisons, it is not reasonable to expect prison healthcare staff to diagnose ABD reliably. The critical safety issue is recognition of severe agitation accompanied by physiological red flags and escalation as a medical emergency.
In 2025 NHS England developed a framework for healthcare roles and responsibilities for planned and unplanned use of force in adult prisons and immigration removal centres which was communicated to all healthcare providers in August 2025. This framework supports HMPPS and Home Office policy documents and makes clear healthcare requirement to attend all planned, and where possible, unplanned use of force incidents.
This framework strengthens the expectations of healthcare staff and provides explicit guidance around warning signs of ABD. This revised framework offers clearer boundaries and ensures that all staff involved in use of force events share a consistent approach to managing risk, including the risk of ABD. Use of force is the terminology used by HMPPS and Home Office and includes the use of physical, mechanical and chemical restraint.
We will be sharing the details of this report with all prison and Immigration Removal Centre healthcare providers with an action to ensure all establishments have a clear red flag criteria and emergency escalation pathway within existing healthcare training structures and operation briefings. This should include a focus on early recognition of deterioration, prompt ambulance activation where indicated, minimising restraint duration and maintaining continuous observation until handover, with routine governance review of such incidents.
In addition, the findings, information and any learning from this case will be tabled at a future NHS England Health and Justice Delivery Oversight Group (HJDOG). The HJDOG is the senior leadership forum, which holds responsibility for the oversight of delivery and continuous improvement in Health and Justice commissioned services, through both national and regional teams. All health and justice related Reports to Prevent Future Deaths are shared and discussed at the HJDOG, and assurance is sought from regions where learning and action is identified.
Regional Response
South East Regional Colleagues have shared reports around the Trust’s PSII and PPOs independent review. South East Regional Colleagues have advised that both sets of reports identify that clinical staff should receive training in managing violence, aggression and mental health crises, as well as the fact some actions taken by staff , particularly around restraint, were not with current guidance and policy. Neither report shared mentions ABD or ‘Excited Delirium’, suggesting that Mr Tarrant’s presentation
was directly related to cocaine use and exacerbated by a heart condition, which the prison staff had no knowledge of at the time, as it was only detected postmortem.
I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Mr Tarrant, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.